STOART RABNERATTORNEY GENERAL OF NEW J

ERSEYDivision of Law

124 Halsey Street 5th FloorP .O. Box 45029

Newark, New Jersey 07101

Attorney for State Board of DentistryBy: K

athy Stroh MendozaDeputy Attorney Gene

ral(973)648- 2972

F I L E DMarch 16z 2007

NEW JER/tY/TAYE BOARDOF MEDICAL EXAMINER''O

State of New JerseyDepartment of Law & P

ublic safetyDivision of Consumer Affairs

Board of Medical ExaminersDo

cket No. BDSME 08245- 20045

IN THE MATTER OF THE SDSPENSION :OR REVOCATTON

OF THE LICENSE OF :

:CONSUELO MENDOZA M.D. :

LICENSE NO . MA30012

TO PRACTICE MZDICINEIN THE STATE OF NEW

This matter was opened to the New Jersey State Board of

Medical Examiners (hereinafter the hhBoard''lupo

n receipt of acomplaint against Consuel

o Mendoza: M .D. CNRespondent'') involvingquality

of care issues pertaining to the care a

nd treatment ofR.D., a three month o1d i

nfant. Specifically, it was alleged th

atRespondent was not sufficiently knowled

geable about basic care andtreatment

of infant diarrhea. Dr. Mendoza appear

ed and testifiedbefore Committee of th

e Board, who, because the doctor was notthe prim

ary are physician for this infant, asked to review various

patient records . Dr. Mendoza appeared before the Committee

a secondtime. The Committee voiced

concerns regarding poor and inadequateX ' .$ j

. .

> 1 W '

-'

,' ; J)! t g. trl b.-; :7.i x.

AND SURGERYJERSEY

Administrative Action

Consent Order

caze, specifically questionably improp e

z yoaagssof recorda as weli

a s '

F poor record keepin yuOffpred Mendoza

an o V * * Yoazd

pportunity to undergo an svaluation yup

ediatrics whéch she compzatsy.

The Board having zevéepad ::e aukzso

ssoos, ysayuyyua ;,stestimony of Reapond

ent at :wo invosy: ayéve in uilV g iea

various patien: records and :ue sssuzts og :a

e

S

soysyssssy

pediatricsy conclude yua: ::e yaars ssyoss y:

oskasyzs

dYdiKdbioD in

discïpiinary action puzsuant to x g s a 4,:z. ,y(s; (,* :. .

Responden. ,ezn, doszsous to seso,ve ,,,

s m

' ' *Dd

recourse to ruzthez roceeazn s

atter wzthoutp , an: tuo soa

z, ,zndzng ,,e .,,,,u

F

resolukion to be in t:e szya zuiasssy au, ,os oou aosss syopapu

,- z- ox --,- -. . . -a- o- ,,,,

q ,

HEREBY ORDERED AND AGREEDTHAT :

Respondent

practice

surrender to

Consuelo Mendoza

medicine and

herebylicense to

Jersey, said

for licensure.

relinquishes her

the state

any reapplication

Suriery

prejudice toof New

be with

2. Respondent shallpay costs in thetranscript andwhich includes

appearances before a

cost of oneamount of $12,278.û1

court reporter for b0th

costs ;

Committee of the Board; investigative

expert's fee

attached ceztxrzaatzon o, cosqs attacuea ve1Q%**A*Y'5 fees (see

made a part hereof) *tO as Exhibit A

and

for review of the file; and

quality

alteration

2

submitted by certified

order made

c/o William

check or

shall be sent

moneypayable to the State of New J

ersey, and

z

Roeder, sxecutive szreator xew asrsey stat

e soardof Medzcal sxamzners p o s, . . ox zaa y

zenton xeu aerao oayrs- oyy,- ye

am ent w,,, se made zn tuezve t,, .

ovee a per,ou o, two years. ,,ze ,,zs, suau p

am en

montbl'- ''am enta

(zo) uays a,ter t,ae ,,z,ng o, ,,,,s o

rdos anu .

% ':'3 be due sen

,sosoysysyuo

payment to se due on tho ,zsst day o. evesy ots

es .

*C' fubsequent

ahaz, se paza at t:e juugment sate as pre

serzbed und

'

,,. er auae . <z-

5. Should Dr. Mendoza

make any tïmelyrequired above tho a

oasd pizz yyyo s ooayyyyosia eg s

vzxment as

amounk due Said certiéicate og seyy pzyy s

s

CYi ZOX 2h*

ïn full the CzDceâled upon paymentamount

of costa féxed sa ove. zff

ail to make any tlmezy paymon: zegul

ssy zn y,,s ovoe

***CCX& Shall

22X' in sole dzscretzon

*' tbO Yoard, accelezate the

Ootstanding and demand immeaiate

CX2i*6 Zmoknt then

payment of suc:

mssoa

faéaure of t:e aoard to so accel

orato ::e amouu: :U

YOCYSE' Pbe

demand payment shaal no: aonatzyuta a wazver or

rozeclalm remedy or rz ut :h : ase anyF g a :uo s

oard may uave unyss yyysparagraph

.

6. This Consent Order shall be a

th- c--p,-,-t. r,- s---, -s-,, --,-,- j--,-,,-,,-- yz-p--ztz-- -,s---

- -, th,- o-d--.

- --,---- t:-

final

fail to

shall bePayment

shall fully comply with the Directi

ves forDisciplined Licensees attached hereto

as Exhibit B and made a parthereof .

Mendoza

DATED :

NEW JERSEY STATE BOARD OF MEDICAL EXAMIN

ERS=#= ,. woo ,0p. v. 0r,- X xoo c , .,p.*. , z y,' gryu .-. atz'. oz': ww's'h. ..; ' .

w w*A '.v--At- ' - p zc . .,., . o, v rE$ 5: : >

-- '

- - - .- - - - -

I have read the within Order.I unde

rstand the Order and Iagree to be bound by its t

erms andconditions. I hereby consent t

o theentry of this Order

C6,,7Consuelo M

endoza M o /oated: J z- o 7

We hereby consent to the form and entryof this O

rder.

Dughi: Hewitt & Palatucci, PCAttorn

ey for the RespondentConsuelo oza M

. D.

Michael J . Keating, Es

Stuart RabnerAttorney General of N

ew Jersey

jj z' 'Yathy Stroh Mendoza

Deputy Attorney General

Dated: 22

* w/ yDated : / / D / C 7

4

DIRECTIVES APPLICABLE TO ANY MEDICAL BOARD LICENSEEW HO IS DISCIPLINED O R W HOSE SURRENDER OF LIC

ENSUREHAS BEEN ACCEPTED

ON MAY 10, 2000AlI Ii

censees who are the subject of a disciplinary order of the Bo

ard are required to providethe information requi

red on the Addendum to these Directives

. The information providedwill be maintained sep

arately and will not be part of the public docum

ent filed wjth theBoard. Failure to provide the i

nformation required may result in further disciplina

fy actionfor failing to coope

rate with the Board, as required by N

.J.A.C. 13:45C-1 et seo.

Paragraphs 1 through 4 below sball apply when

a license is suspended or revoked or

permanently surrendered, with or without prejudice

. Paragraph 5 applies to Iicensees wboare the subject of an orderwhich

, wbile perm itting continued practice, contains a probation

or monitoring requirement.

1. Document Return and Agency Notificatio

n

BY THE BOARDAPPROVED

j

'Fhe licensee shall promptly forward to the Bo

ard office at Post offfce Box 183 l4c East

yj

y

Front Street, 2nd floor, Trenton New Jersey 08625-0183 the ori

ginal lfcense current

j

biennial registration and, if applicable

, the original cDs registration. In addition if the

Iicensee holds a Drug Enforcem ent Agency (DEA) registration

, he or she shall promptly

advise the DEA of the licensure action

. (wjth respect to suspensions of a finite term

, atythe conclusion of the t

erm the Iicensee may contact the Board office f

or the return of thej

.

docum ents previously surrendered to tlne 8oard I

n addftfon at the conclusion of the term

the Ifcensee should contact the DEA to advi

se of the resum ption of practice and to'ascertain tlne impact of that change upon his/her DEA

registratfon.)2. practice cessation

The Iicensee shall cease and desist from engaging in the practice of medi

cine in this State.

This prohibition notonly bars a Iicenseefrom rendering professional s

efvices, butalsofromproviding an opinion as t

o professional practice or its application

, or representjnghim/herself as being eligible to practice

. (Although the licensee need not afirmativelyadvise patients or others of the revocation

, suspension or surrender, the licensee m ust

truthfully disclose his/her licensure status in r

esponse to inquify) The disciplined Iicensee

is also prohibited from occupying, sharing or using

office space in which another licensee

provides health care services. The disciplined Iicens

ee may contract for, accept payment

from another licensee for or rent at fair market val

ue office premises and/or equipment

.

ln no case m ay the disciplined licensee auth

orize, allow or condone the use of his/her

provider num ber by any health care practice or any other licensee or health

care provider.(In situations where the Iice

nsee has been suspended for Iess than one gear

, the Iicenseemay accept payment from

another professional who is using his/her office during the

period that tbe licensee is suspended, for the payment of salaries for ofsce staffem

ployedat the time of the Board a

ction.)

general circulation in the geographic vicinity in which the practi

ce was conducted.

At theend of the three month period, the licensee shall fil

e with the Board the name and

telephone number of the contact person who will have

access to medical records of form er

patients. Any change in that individual or his/her telephone number shall be promptlyrepofted to the Board

. W hen a patient or his/her representative requests a copy of his/hermedical record or asks that

record be forwarded to another health care provider

, thelicensee shall promptly p

rovide the record without charge to the patient.6. Probation/Monit

oring Conditions

W ith respect to any licensee who is the subject of any Orde

r imposing a probation or

m onitoring requirement or a stay of an active suspension

, in whole or in part, which isconditioned upon compliance

with a probation orm onitoring reguirement

, the Iicensee shallfully cooperate with th

e Board and its designated representatives, including theEnforcement Bureau of tb

e Division of Consumer Affairs, in ongoing monitoring of theIicensee's status and practice. Such monitoring shall be

at the expense of the disciplined

practitioner.

y

(a) Monitoring of practfce conditions may include

, but is not limited to inspection

of the professional premises and equipment

, and Inspectfon and copyfng of patient records(confidentfality of patient identity shall be protected by the Board) to verify compliance withthe Board Order and accepted standards of practice

.

(b) Monitoring of status conditions for an impaired practitio

ner m ay include, butis not limited to

, practitioner cooperation in providing releases permitting unrestrictedaccess to records and other inform

ation to the extent permitted by Iaw from any treatmentfacility, other treating practitioner, support group or other individual/facility involved in theeducation, treatment, m onitoring or oversight of th

e practitioner, or maintained by arehabilitation program for impaired practitioners

. If bodily substance monitoring has beenordered, the practitioner shall fully cooperate by respondi

ng to a demand for breath, blood,

urine or other sample in a timely manner and providing th

e designated sample.

NAME: Consuelo Mendoza, M.D.NJ Li

cense #: MA30012

ADDENDUM

Any Iicenseewho is the subject of an orderof the Board suspending, revoking or otherwiseconditioning the Iicense

, shall provide the following information at the tim e that tb

e orderis signed, if it is entered by consent

, or immediately after service of a fully executed orderentered after a hearing. The information required h

ere is necessaw for the Board to fulfill

its repoding obligations:

Sociaj Security Numberl:

List the Name and Address of any and aII Health Care F

acilities with which you are

affiliated:

List the Names and Address of any and aII HeaIth Maint

enance Organizations with whichyou are affiliated:

Provide the names and addresses of every person with whom you are associated in yourprofessional practice: (You may attach a blank sheetof station

efy bearing this information).

Pursuant to 45 CFR Subtitle A Section 61.7 and 45 CFR Subtitle ASection 60.8, the Board is required to obtain your Social Security Number and/orfederal taxpayer identificati

on number in order to discharge its responsibility to repodadverse actions to the National Practitioner Data Bank and the HlP Data Bank

.

INancy zr-ecca - F44 0361246.pdf Page tJ '

DM SION ()F LAW TIMZKEEPING iIYQTeCMTIMESHEE.Y REPORT

f)ltCi: F44 MCNDQM ! KATHY STRQHJSt:;'r Acrpm cotf MAN'E

./I MAAR'ER KAME()7/(1*.7.%5 ce criznzzd MeNIX)CA

. CouAlEkïl 34 D. 1%K IAL.: *.7

AGT AQTbATC C O Dk577:7/2:25 C C v

Tjhsf FRT'MAfî7jaiz*l

iil-l- Blt.kQotft O BO DEMb24

TIM.E VAT'I'';q MATTER NAM:

.5 J-.*1246 ME&DOZA CDNFJELQ Nl D . I!dO

.5

A.c' pmöATE GQD: MATT:R MAD'F

R M MiW/iz/M5 CJCM D3.6120 MFZDOM GDNSUKO ld.() 1V0

'/OYAL:

K X ACYOA'SE CLEIDa 'IIME MATTE'R MATTER NAM;n7A?12Qk%.s IDIIM .S ()2..1::74, W NDO;!A GONIPJVLO

. M.D.; I&40TDTAL; .& '

ACT ACTDATU GODE%ll2z%%* tië GC14

K TAL:

51Lk RILLCODC NuBçoli

BIUL BILLCODE :IPiFODDE

NICX

QILL BltL1095 NOEGOOEMEV

MATVER

c164248MAUER RAMK

MVNBOZA CONIFQILO. M (A . IMO

LSLL BpytCO D5 g 0 HLO PENt'X

G2 : 9: 2.30: G'; -1E'k.1 Z r)' *7; 2 2 r. . Q 1N ) '-o : X P 1

pk a n cy Zeccla - F 4 4 0 3: 1 248 ,p,,... ci f

Pag e f, ti

DMfPRTMA DIVISION llfr LAW TIMQKEEPINB I;YeJE.MTIM/SHF

-ET REPORTDAG: F44 MENDOR KATHY STROH

3124T1747

Jtû'f Af:'TLSA':E (IQD: nME(272 ) IWM C (7&.1 2. t)

MJK'ETER MATNR NJAME::+6:2* MENX ZA CONSUGO M

.(7 . !&lQ

ACT ACI'DATE CODE 'rlc MATTE;

MAUER NAW&/17/2% c'.>.rs 7 () ()3.612z.8 MENDC)M ctrlNêAlEt.t:t M (:.. 1:/1

I'CSTX.: T4

Af'r AQTDATC COD: Tle MAUER m 'f-rfa NAME()N:1.,2:2tt1 (2M: * .6122.: W NDQM COIXUELQ M D

. IMOTQTMZ

hCY AGTDATE CODB TIME MATYEA M

AUSR NAMC* 771T.%6 C;kA * 7248 M

DNIIOIJQ CONSLIE.Q K4.() . lMOYOTALI '

AU ACTDATB CODE

f%: 1srz5* C()MMAI-TEIF MAYTER AIAMD(r.*612:4 W NX ZA COND ELO

. KID.. IMO

BILL BIL.LX )>E CUM OW

MEx

HILL BikLCO DQ & UBCD DE

BILL :ILLCCQDG :ILf:X C:R

M9t

Bluk BlkkC = DE ; UBC D Dt

KLL QILLX DE :ttElcox

20 0?; % T JEACfro..pal:p,oop q . xp u

Nancy Zecca - 17440061248.pdf Paqe 9 E

TIMQPRTVA ()$VI.%l()N OF LAW TIMDKEEF'IMG SYSTEMTIMKSHCET REPORT

FR MENDOZA KATHY/TRQH

*Tç1112W7

&CT AWDATE O D: TIG MATTER MGTTEIr NAME

(N/dpQ(#.26 CCM 1 9 *3.6:20 KGNDOZA CONSUELO. M 0.. 14.GQYOTAL: 1.r

pc'r ACYDAT: (IODC Tthlf w k'l''rtR MATYER NAME

4162.*2126. CCM .E o:>.6rNg F.TSNZIO.Z.N JON. S'Ufwo. M D . 1,A7

#QC F?TDAYE Coor MArr:q

yœzazxf CCM 916424:

Tofaù l.a

ACr ACTDATE QJD: KMf MATYtR:Of2TV2@2 CF'it 3.Q (M 3248

MAFTER <A%.1F

?./IENIIO;..A. CC7NSUEt.(h. M.t) . IM(7

œt.l- ml..tCODC VLIBCOPZ

BJLL R LLCBDQ ; UBCO UENI/X

BILL a LLC/RQ BUBCQDE

MATYER NAME

vFzkDoz'. GONSUQLO. M.O.. Prvbz

RILL g!bLCJDZ :UBCODEMEX

ACT AC7DJLT: cfnte TlMiE MA'ITER MATTER NAME

4(i/2&LXr.6 2/.9 : 1 02..6124: VFNCIOZA. CONEUKLD. H.DTCTAL: 1 c

R'LL BILLCODE SUACODEMEx

9 2 : 9 T 2 0 O J S T J P H Z 9 rz c' 8 '-zu Q':' uç F; : X E' -1 CRVI'-I ' Jf'l ' PhTt''s

riarirz'y J.e= a - E4423: 1 2*8.pw'1f Pa e 1 Q

TIMQPRTVA OIVISII)N OF QAW TIMQK/ePING SYSTEM

TIMESH/CT Rlle p'fDAG: F44 MENIICLW FA'FHY STRI)H

ACT ACYDATJ CoDt Mnm q M

A> R NA<nlsef?A3 MGNODZA CONSIJKO

. M D.. IKIO

ACT ACT(MTE Uope MME MATTER

MA.YTEA G MEIIW FZ:C6 ZCk 1 t/ 0:+6124.5 ME#OOlA. CIM SUCLQ, M.D. IM(1

TOTALI

M 'f AcTDAH GUDE MA'CVR

MATTSR NAMRlt/K.''D:fk CCN 13.632.49 MZNDCP;A CCIPISUELO; tu D /KK)

Torpt.l

#.(7T I*CTDAT: CODE TIM: MAT'NR M

ATWR NAME42.859r.:42* ()C# (M I:> MENDCiZA CçriMsutt.Ci M D. tie

IO ALZ

A(21' AmDATE COW MATTJR MATH R NAM:()14C2/,M 7 (;W 061248 M

ENtLO;!.K CONSIJFJX . Nî.D.. (t<!C'fou k.:

COD; SUBCODC

!/C>2

Bltk BILLC G Dg : 0 eQ Q D<

> LL BILQ10 DE S : BC O QfN#f'

BlLL lpltAO DE :IIBID I)'

E'lt.k :lt1.ccllâg SLIPGOD:

MF.X

92 : 9T 200: S'C 2E'1'1'59:,2 Fltro.e, J q : xp 4

STATE OF NEW JERSEYDEPARTM ENT OF LAW & PUBLIC SAFETYDIW SION OF CONSUM ER AFFM RSBOARP OF MEI:ICAl. EXAM INERS

STATE 012 NEW JERSJI-Y )SSCOtJN'l'Y OF ESSE,X ) CERTIFICATION OF COSTS

1. Michacl J. W ôstenbergerx of full agfz. do hereby certity:

l 144 employed by the Enforcemcnt Bureau/professional Soards, Divislon t)f ConsumerA f-flkirs- as a Supervisinû lllvestigator

. As a reistïlt of nny hoiding this posstion, l am aware of the

investigative activities which havcbeen undertaken by the Bureau's slaff in conducting tnvestigative and

related activities conoerning Consuelo L, Mendoza, M .D., under Bureau I''iles //1 0-4734-99-34 1 and

#J 0-4734-99-34 1(S- 1). The period of these assignments was approxlmately Maroh 1 5 . l 999 throughOotober 24, 2000.

The tolal hours spent on Ass' ignment :1 0-4734-99-341 was 9 hotlrs and 25 m inutes($ 1 10.07). The cost of 'this investigation was $1

.044.02.

The total hours spent on Assignment #10-4734-99-341 (S-1) vvras 9 hours and 50 nlinutcs,

T1II.) total costs of the abovc stated investigafive activity ig obtaiacd b), multlplying time (9 hours and 50

mitwtes) by l .4 1 (for a total of 1 3 hours arïd 51 minutes) by the (then) s'tarldard rale of $94.72 per hottrto determine the total billable hours (as explained by the attaohed Revised E

nforcement CostRecovery/ldourly Rate Detennination). Such calculations yield a total of S1

,31 l .87.The grand tûtal of both assignments was $2

,355.89. No aclditiolla.l expcuditure wasincktrrod.

1 certify that al) of the information which is containcd berein and which îs based upon mypersonal knowledge is trut. I am aware that lf any of tbe infûrmation is willfuily false

r 1 am subject topunishment. W ith respect to the infbrmation reportrd by me which the conlôxt disclosed is not basedon roy perstmal knowledge, f cerlify that 1 have reponed in good faith and to the best of n)y recollectionaan accurate acootmt of thc informatlon as reported to me.

'

vyéDate:

lvl-fsv:sa

ichael J. h'estenbergerSupervising lnvestigator

200: %'f JET.I C9t-28t79226: Xk'H 17)' hf -1 ' M f'l ' .q T f7

HRIETINE TODD W HID ANGomernor

#' *

11

A tatz zxf Nefzx TersevDEPARTMOIT OF L'Aw A&D PUBUC SAFETY

DlvlsioN OFCONSUMP AGAlF.sADMISISTRATIONl24 HAIPEY S're . 7)41 PLOORX NEWARX NJ Johftk J. FARMERO JR.

Attornrv GenerolM ARK S. HERR

Dîactor

Arfa//frlg Asldress':

t>-O. Box 45:24Nmvw'k. N1 97 1 0 1

(973 ) 504-.63 74REV ISEDENFORCEM ENT COST PXCOVERY/HOURLY P

XATE DETEPM INATION

The hourly raîe is deTermined based on the lotal salaries of tbe Enforcemen! Bureau divided bytotal investigator hours. Total investigator hours consist of case specific investigator hours artdnon-case specific investigator hours. Case specific hours include invesTigator tirne spent on such

activities as investigalions, inspections aod report wfitirtg. A1l of which can be directlyattributed to a specific ca-se. Non-case specific hotlrs includes tîme spetlt by irtvestlgators that al'eriot cxasily attribuoble to a specific case. 'fhis includes time spent on such activities as tmvel andadminislration.

Tbe total number of invesligator hours divided. by tl'ie cage specific hours provides a ratio tha: is

applied to the number of hours that are directly billed to a case. This valculatton duerm ines the

number of billable hours. The billable hou:s times the hourly rate is how we detelm ine costs tobe recovered.

By using this methodology, al1 related costs, direct and indirect, are recovered.

Effective 7/1/99

5198 kirlno -3 ihlk ff; ZJ

D j /. i ! ,' . ' ' ' : . :k/ ' 't. .:;.

oe ,.z va ,g. tb1

:; ik t'!r k -.. I ,i!t 1--. J--./

82..9: 290C GT.7r1:)17,.7 2r' QQ? G - X'p a

nt 2 f-.J 6 - ! () '. () 3 L 2 h

. . o . flv 7 4 5 . 17. '(DDCUMEST aqyc/ acy cySTATE OF N JERSFY G ''

PER1 PAYMENT VOUGHER -

w- unv- uueea .-vc,- v oMsa# NDOR INvoIcE).

sp serAvr scano pA; cx: (p'w p Rg cx (A) vsrloo. s ;CV

ull: A 'ry Fu lrl <IMUER kev ov 6 Mo :Y M'R Mo ov tq I

Bo : l

cobnnxcr No Ac-e-;v qrr atlrsq (:) = Rvs xxx I- o ticmtw s yo: (c) TOTAL Auotv

PAYU I co Mo rfo s

(n) PAYEE NAME AND ADDRHSS (E) SEND COMPLEYED F0RM TO.Rlchard Lander

. M.D Stale Board of Medical Examiner.s2:15 Hllsslde Avenue P.O' BQx 1B3Ll

vlngston New Jerwey 07039 Trelftm. NeW Jerit'y 03125

(F) PAY6E DECkARATIONSl QERTIFY THAT I'HE W ITHIN PAYMENT VOUCHFB 1XCORRK T 1è1 ALL ITS PARIV IJLARS. THAT O E OESCRIBED

VE BEEN FDRNISHED OR Q'QZ.QGOC.)DS (:)!? SERVIGES FIAREKDERE

D AND THAT NO BOHUS *AS RFEN GrVFN OR r y j xF'AYF..E SPGNATUR .

REGEIVED DN ACCOUNT OF SAID DOCUMEST. ,

N r, jj ( c. j.PAYFF TfTt,E; BILLING DATE

45 REFEAENI:Q 4C() PAYK REFERECNGE)

..- GD .-. ...- AGY ...- NA SER ... -. UNE.-!

2'3

FUNU AGCY ()kG C.DDE &VIB-IM G APFM tl#l-f A (7D DBJECT (;D StlF.f+J REV SRGE SUB-REV PROJECT/JIZ N()

3

RPY CT B: ACT DT DESLRSMSDN QQAVT?Y AMQUNT ID PF T#

2.7:!1

.(TQM Co- ln O DFJDISCRIPTIY 59 ITEM Q U&lT tlrlf'r PQICE AMQUNTN(7. .

Vaner of lnveslm' R>' -of -î Hovrs hoqrs $24:1()

.00 $ 3of-.J :-.x.VCenb-tleko Mendoa, M.D.

Review of records and preparation of Hotlrs hours :350.00 $report; per Iee agreement

Dates of Selvjce: Houo hours $ $Testimcny b'me

, if r> tlired

Total

TOTAI-RDKCATIONPT PIGXMm M ENCY

. IG M - - - K- - - Y GERTFCRTKAKVAAFROVAL OF'fER. Ie ee lNz Pe alue èteVJRC rpt- > - <*- e - I.e - a - .

. ... :: '

F*e 5me F*m 0-*

cr *4B

iï7', 'c1 67: 917 .706): GJ JE'H (59p28:::

,?.6 : xE'4 nw'a ' 1rn - n v=

& A)-/ O NEW J 9S Y pocuvsNr BATOH xocwoPAYMENT VODCHER Tc Auv Nuvôna Tc AGv têuMsyq pao px(VFRDC)R lNvolCE)

F'P STAR'r &CMED PAY chlK oFF F J!F (;K (#) VENI)ORP O #. v'v (MTE Mo ().g yn uo r)Y y'a (>T LIAB A 'rY FL ID NUMBER

sEE INSYRIJCTIONZ F09 (c) l'o'rAu AvouN'rCONTRACT *, AIIENL'Y RrF. BUYER H TFRMG çc

xxl O MPLETING ITEMS (A)THROIJGH (a).

D PAYEE NAME AND ADDRE9S: E SENP X MFLETED FORM D ;BICNARD LANDE ,R MD Ne'w JERSE'Y STATE BOARD OFMEDhIML F-KAM/NER;203 HillAicie Av-qllu: Pc) Bo4 ! K#L...y1 IP

.II>IPP,...N- Jerpy 07139 Trenllm NJ :8*:$

(0 PAYEE DECG RATION/: '

1 Cfix-all-f' THAT THE WITHIN PATMENT VCUCHEB S I7(7RRhrI IN C) F'A...p EZ)ALL ITS PAFITIGOLAR:, TMAT THE DEISGRI8ED GO DS Qq SERVICFS PAYEE SIGNATUREHAv: Biretk/rup-sbeo oq Ruxpeu o Axo-rnAr No aotes Has

BE&k cllvEhfon qscllpso o: sccokllér o: smn oocklvszr. Gtmsultant Q April 1'B 2006F'AYEE YITL: Blk.LlNo DATE

1R E: F E R f! N C EQINE No. (7o A fl (; Y NUMBEFI UNE C1 P A Y i5 E FI E F E lq E hl f.r ri

3 - .. - . - .-.- -.-..- --. . - -. - ...,. ...-.-.-. ..- --- .- -...-0 c-.c'-,leuay.-k Mtqtoa, Mo - ajy-Aczœ-!a23

:uB. ae?R KFIV;TYRJND ACK Y OHII GODE ORt$ CJNIT x os owl/c; c;a SLN-S-C)!D Rev ;RI)E &LIB-REV ;

..% (NEc:r / lc): Njo.1 1 X 066 1 Q10 YIAW

R3

RFT LT B; AGT DT DEr qlprKm tltG rn A M O U y T lp PF rx

23

ITEM N(X COMMODITY X DE/DCSGRIPTIDN OF ITF.M OUANTITY UNm U&IT PRIGE A M 0 U N 'r

t/eo Cznauelo L Mendoza, MD . 7.58+ *17 91 Rw law ol r/cozdm A proparatlon ofsuppleraotal Rppprt per f*e ppreernent ï.5 $/.M111 ,$2X / hour L30().()0

T 0 T A L - - .- ..v- -.- ..-- $3:0,0:

ERTIVDCAXON MY'REW MNU ASENW J I CA // lMl P# .te.: Mœ t- o CERNROAY N 8'F A998(h%*4G DFFI/ERZ l e e I)< F:)*ïêry koo ? Nt- ztvpe crmp)e ro re as AMe e ed a jA, :rx1p:g- K plpnws:t

s 1 p n a ! u r e Aulhyzlze :ie ore

I'f 1 f I e D a 1 (1 T t l l e D s l (h

200:Ftlr 71 1 4/2726 8 Q:5 li*puohe.f

aplsl C9172879226 : XE'.:1 tn:7 ' 4-t '''%Tf7

i!

lJN THE M AU ER OF'. !

!iCONSUELO M E

' NY OZA, M .D. :13!1

AFFIDAVIT

TO W HOM IT M AY CONCERN :

1, W illlam V. Roeder, of t'ttll agex deposo and say;

I am the Executive Director of the New l'ersey State Board of M edicalExaminers tthe etBoard''), having offices at 140 Easî Front Street, Trenton.New Jersey 0860$, and a.rrt rbe official custodian of tlze records of 6

ne Board.

1 have .directed that a diligent search be made of the Boazd records in thealxwe-captioned m atter relative to certifiod shorthandrcporting costs incurredb

y the Board in it.s proceedings. Attached is a certified true copy of' thtz Newlersoy paym ent voucher indicating that the certified shorthand reporting costsincurred in this matter total $598

.35.

DATE'. Novem ber 27. 2006

i V ' - -am , oeder, cu e irector

STATE OF NEW JERSEY

COUNTY OF MERCER

swom aud sttbsctibed Before Meon (his VVW clay of Novembev 2006

.z y'----...,.((:5;, ...-.' '

y

SP S* * >

ç- -rKJ ycwovo

r' ir ' d :::9: 200: GT 22/4:9:28:9226-.X94